14100008 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19160 TWIG LN CONTRACTOR:JEREMY MAO INC PERMIT NO: 14100008
OWNER'S NAME: LIN FELIX CHANGMIN AND RUBY C 13212 CARRICK ST DATE ISSUED: 10/01/2014
OWNER'S PHONE: 4083238473 SARATOGA,CA 95070 PHONE NO:(408)449-9942
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL E]
R / �A INSTALL TEMP POWER
License Class .J/ Lic.# �l .�f-��' �/
Contractor 1,r�.n7 /!/1.g��/(,�_Date /0 �i 710/7"
IV
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$500
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:37508021 00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITBIIN 180 D RMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS F M LAST C ED INSPEC N.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the `
Issued by: Date:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18.
'2 Z� RE-ROOFS:
Signature Date /. All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:`/( �l
permit is issued. t
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9 18.
Signature Date
GENERAL PIERMI-► APPLICATION $ MEP
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TOTAL V k i LTA.TiON:
By ny Sip a LTe below,I ce;`tij?to e2Cb 0_h'lollowine: I&M the property o:mer or au hor iud apnt to art on 4' 'r0 er`S behalf. I hFve read&};s
application and the infor ration I have provided sr
coed I have read the Description of)-)Vo-.I-and ve;,y it is ace�-ate. i a�Tee t0 c0 nDly vrith all applicable local
o:dinuices and state 1a,%,s re_latma t0 buile ne conSuVction. I authori%e.reDresentn ves Of Cupt,tLino to enter the P bove-Idtntiftd^Dro-ot,for L mtnon Du-Moses.
SI�tEtare Or Appllcant'Ak nt - Date
SUPPLEAC-INCOIRhLkTI'ONTR U=D
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hl.F.P.iljisct'p;�2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 19160 twig In DATE: 10/01/2014 REVIEWED BY: Mendez
APN: BP#: *VALUATION: $500
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY PENTAMATION 1 REAP14
USE: SFD or.Duplex PERMIT TYPE: A
WORK install t mp power
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Temporary Power 1ERT<200 100 Amps $48
TOTALS: $48.00
�A-.
t o T u",Ch 1'nwh.. /Ctn('re�I Elec.Plan Check 0.0 hrs $0.00
9ech_ 1"!rmil Fee: 11him1. 1'er nib T'e<;: Elec.Permit Fee: IEPERMIT
odlef I',urral7 Inv). Other Elec.Insp. 0.0 hrs $48.00
1'lzmib.Insp. Fee: i.7S
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These fees are based on the prelimina information available and are onl an estimate. Contact the Dept-for addn'1 info.
FEE ITEMS (Fee Resolution 11-053&.. 7/1/131 FEE QTY/FEE MISC ITEMS
11161n Che(:�I,
PME Plan Check: $0.00
l'c>rmil
PME Unit Fee: $48.00
PME Permit Fee: $48.00
(.C)i2Jf1'I.tL'f3�)PZ 1{j;l',
Administrative Fee: IADMIN $45.00
Work Without Permit? 0 Yes (F) No $0.00
I:/,,alw'!rl 1`Iarming 1"ees:
Travel Documentation Fee: ITRAVDOC $48.00 i
Strom Motion.Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldp,Std s Commission Fee: IBCBSC $1.00
a=_° $190.50 $0.00 TOTAL FEE: $190.50
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Revised: 08/20/2014